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Committee Opinion No. 678: Comprehensive Sexuality Education

ABSTRACT Current sexuality education programs vary widely in the accuracy of content, emphasis, and effectiveness. Data have shown that not all programs are equally effective for all ages, races and ethnicities, socioeconomic groups, and geographic areas. Studies have demonstrated that comprehensive sexuality education programs reduce the rates of sexual activity, sexual risk behaviors (eg, number of partners and unprotected intercourse), sexually transmitted infections, and adolescent pregnancy. One key component of an effective program is encouraging community-centered efforts. In addition to counseling and service provision to individual adolescent patients, obstetrician–gynecologists can serve parents and communities by supporting and assisting sexuality education. Because of their knowledge, experience, and awareness of a community’s unique challenges, obstetrician–gynecologists can be an important resource for sexuality education programs.

Committee on Adolescent Health Care: This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care in collaboration with committee member Joanna H. Stacey, MD.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Copyright November 2016 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Recommendations and Conclusions

The American College of Obstetricians and Gynecologists (the College) makes the following recommendations and conclusions:

• Comprehensive sexuality education should be medically accurate, evidence-based, and age-appropriate, and should include the benefits of delaying sexual intercourse, while also providing information about normal reproductive development, contraception (including long-acting reversible contraception methods) to prevent unintended pregnancies, as well as barrier protection to prevent sexually transmitted infections (STIs).

• Comprehensive sexuality education should begin in early childhood and continue through a person’s lifespan.

• Programs should not only focus on reproductive development (including abnormalities in development, such as primary ovarian insufficiency and müllerian anomalies), prevention of STIs, and unintended pregnancy, but also teach about forms of sexual expression, healthy sexual and nonsexual relationships, gender identity and sexual orientation and questioning, communication, recognizing and preventing sexual violence, consent, and decision making.

• Obstetrician–gynecologists can serve parents and communities by supporting and assisting sexuality education, by developing evidence-based curricula that focus on clear health goals (eg, the prevention of pregnancy and STIs, including human immunodeficiency virus [HIV]), and providing health care that focuses on optimizing sexual and reproductive health and development.

• Obstetrician–gynecologists have the unique opportunity to act “bi-generationally” by asking their patients about their adolescents’ reproductive development and sexual education, human papillomavirus vaccination status, and contraceptive needs.

Comprehensive sexuality education should be medically accurate, evidence-based, and age-appropriate, and should include the benefits of delaying sexual intercourse, while also providing information about normal reproductive development, contraception (including long-acting reversible contraception methods) to prevent unintended pregnancies, as well as barrier protection to prevent STIs (see Box 1). Comprehensive sexuality education should begin in early childhood and continue through a person’s lifespan. Programs should not only focus on reproductive development (including abnormalities in development, such as primary ovarian insufficiency and müllerian anomalies), prevention of STIs, and unintended pregnancy, but also teach about forms of sexual expression, healthy sexual and nonsexual relationships, gender identity and sexual orientation and questioning, communication, recognizing and preventing sexual violence, consent, and decision making. They also should include state-specific legal ramifications of sexual behavior and the growing risks of sharing information online (1). Additionally, programs should cover the variations in sexual expression, including vaginal intercourse, oral sex, anal sex, mutual masturbation, as well as texting and virtual sex (2). The American Academy of Pediatrics provides an overview of the published research on evidencebased sexual and reproductive health education (3).

Box 1.What Constitutes Comprehensive Sexuality Education

The following are components of comprehensive sexuality education:

• Comprehensive sexuality education should be medically accurate, evidence-based, and age-appropriate, and should include the benefits of delaying sexual intercourse, while also providing information about normal reproductive development, contraception (including long-acting reversible contraception methods) to prevent unintended pregnancies, as well as barrier protection to prevent sexually transmitted infections.

—Emphasis on human rights values of all individuals, including gender equality, gender identity, and sexual diversity, and differences in sexual development.

—Encourage consideration of implants and intrauterine devices for all appropriate candidates.

—Participatory and culturally sensitive teaching approaches that are appropriate to the student’s age as well as identification with distinct subpopulations, including adolescents with intellectual and physical disabilities, sexual minorities, and variations in sexual development.

—Knowledgeable about and inclusive of statespecific consequences of sexual activity during adolescence, including online and social media activity.

—Discussion of the benefits and pitfalls of online information (eg, gross misinformation on sexuality in cyberspace).

Current Quality of Sexuality Education

Current sexuality education programs vary widely in the accuracy of content, emphasis, and effectiveness. Evaluations of biological outcomes of sexuality education programs, such as pregnancy rates and STIs, are expensive and complex, and they can be unreliable, often relying on self-reported behaviors to measure effectiveness. Between 1996 and 2010, there was a strong emphasis in sexuality education on abstinence until marriage because of federal and state funding bans on comprehensive information about contraception. Several states have responded to parents’ and communities’ calls to provide education on not only abstinence, but on contraception, STIs (including human immunodeficiency virus [HIV]), and the proper use of condoms (4).

The Role of the Obstetrician–Gynecologist

In addition to counseling and service provision to adolescent patients, obstetrician–gynecologists can serve parents and communities by supporting and assisting sexuality education by developing evidence-based curricula that focus on clear health goals (eg, the prevention of pregnancy and STIs, including HIV) and providing health care that focuses on optimizing sexual and reproductive health and development, including, for example, education about and administration of the human papillomavirus vaccine (6). Because of their knowledge, experience, and awareness of a community’s unique challenges, obstetrician–gynecologists can be an important resource for sexuality education programs (7). Additionally, obstetrician–gynecologists can encourage patients to engage in positive behaviors to achieve their health goals and discourage unhealthy relationships and behaviors that put patients at high risk of pregnancy and STIs. Clinicians also can evaluate adolescents’ level of engagement in risky behaviors, including those occurring online, and educate patients and guardians of the risks of social media and the Internet; and provide support to the parents and guardians of adolescents by encouraging them to be actively involved in their children’s sexuality education. Obstetrician–gynecologists have the unique opportunity to act “bi-generationally” by asking their patients about their adolescents’ reproductive development and sexual education, human papillomavirus vaccination status, and contraceptive needs. Although obstetrician–gynecologists are well-suited to provide sexuality education, some may encounter obstacles; local laws have been proposed to restrict family planning providers from giving sexual health information to adolescents outside of a medical setting (a physician’s office or community health clinic) (8).

When a responsible adult communicates about sexual topics with adolescents, there is evidence of delayed sexual initiation and increased birth control and condom use (9). Although many parents talk with their adolescents about risks and responsibilities of sexual activity, one third to one half of females aged 15–19 years report never having talked with a parent about contraception, STIs, or “how to say no to sex” (9). Community and school-based programs also are an important facet of sexuality education.

Effective Programs

Data have shown that not all programs are equally effective for all ages, races and ethnicities, socioeconomic groups, and geographic areas; there is no “one size fits all” program. However, one key component of an effective program is to encourage community-centered efforts. Innovative, multicomponent, community-wide initiatives that use evidence-based adolescent pregnancy prevention interventions and reproductive health services (including inclusion of moderately or highly effective contraceptive methods, such as long-acting reversible contraception) have dramatically reduced pregnancy rates among African American and Hispanic individuals aged 15–19 years old (10). Although formal sex education varies in content across schools, studies have demonstrated that comprehensive sexuality education programs reduce the rates of sexual activity, sexual risk behaviors (eg, number of partners and unprotected intercourse), STIs, and adolescent pregnancy (11). However, despite concerns raised by some involved in health education, a study of four select abstinence-only education programs reported no increase in the risk of adolescent pregnancy, STIs, or the rates of adolescent sexual activity compared with students in a control group (12).

Reaching Special Populations

Adolescents with physical and cognitive disabilities often are considered to be asexual and, thus, have been excluded from sexuality education (13). However, they have concerns regarding sexuality similar to those of their peers without disabilities. Their knowledge of anatomy and development, sexuality, contraception, and STIs (including HIV), should be on par with their peers, and they should be included in sexuality programs through their schools and communities.

Comprehensive sexuality education should not marginalize lesbian, gay, bisexual, questioning, and transgender individuals and those that have variations in sexual development (eg, primary ovarian insufficiency, müllerian anomalies). Curricula that emphasize empowerment and gender equality tend to engage learners to question prevailing norms through critical thinking and encourage adolescents to adopt more egalitarian attitudes and relationships, resulting in better sexual and health outcomes (14).

Online Communication and Using Cyberspace as a Source of Information

Adolescents may use a variety of media sources to fill in gaps from the sexuality education they receive from schools, community programs, and parents; thus, media literacy is increasingly a key factor in children’s sexual health. Three quarters of adolescents use a social networking site, more than 80% own a cell phone, and the Internet is available to almost all adolescents at school and home (15). Comprehensive sexuality programs should consider the benefits and pitfalls of social media. Adolescents should be aware of their “digital footprint” and the physical and legal dangers of their online behavior (1).

There is a growing interest among adolescents to access sexual health information online that is written in language they can understand, that is in an interactive format, and that is presented in an entertaining manner (16, 17). Educational opportunities may be limited by the Internet because popular search engines often will include inappropriate sites or pornography as the first available choice, and some reputable sexual education sites will have their content blocked by social networking sites as “offensive.” Finally, adolescents are not likely to seek out and follow an organization through a social networking site, but will heed an RSS feed (an aggregation of information, including blog entries, news headlines, audio, and video) or text messages (18). For more information, see Committee Opinion No. 653, Concerns Regarding Social Media and Health Issues in Adolescents and Young Adults (1).

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/Comprehensive SexualityEducation.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s web site, or the content of the resource. The resources may change without notice.